Psychological Disorders: Schizophrenia
American
Description
A. Characteristic symptoms: Two (or more) of the following, each present
for a significant portion of time during a 1-month period (or less
if successfully treated):
delusions
hallucinations
disorganized speech (e.g., frequent derailment or incoherence)
grossly disorganized or catatonic behavior
negative symptoms, i.e., affective flattening, alogia, or avolition
Note: Only one Criterion A symptom is required if delusions are bizarre
or hallucinations consist of a voice keeping up a running commentary
on the person's behavior or thoughts, or two or more voices conversing
with each other.
B. Social/occupational dysfunction: For a significant portion of the
time since the onset of the disturbance, one or more major areas of
functioning such as work, interpersonal relations, or self-care are
markedly below the level achieved prior to the onset (or when the
onset is in childhood or adolescence, failure to achieve expected
level of interpersonal, academic, or occupational achievement).
C. Duration: Continuous signs of the disturbance persist for at least
6 months. This 6-month period must include at least 1 month of symptoms
(or less if successfully treated) that meet Criterion A (i.e., active-phase
symptoms) and may include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of the disturbance
may be manifested by only negative symptoms or two or more symptoms
listed in Criterion A present in an attenuated form (e.g., odd beliefs,
unusual perceptual experiences).
D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder
and Mood Disorder With Psychotic Features have been ruled out because
either (1) no Major Depressive, Manic, or Mixed Episodes have occurred
concurrently with the active-phase symptoms; or (2) if mood episodes
have occurred during active-phase symptoms, their total duration has
been brief relative to the duration of the active and residual periods.
E. Substance/general medical condition exclusion: The disturbance
is not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical condition.
F. Relationship to a Pervasive Developmental Disorder: If there is
a history of Autistic Disorder or another Pervasive Developmental
Disorder, the additional diagnosis of Schizophrenia is made only if
prominent delusions or hallucinations are also present for at least
a month (or less if successfully treated).
Diagnostic
Criteria of Schizophrenia Subtypes
Paranoid
Type
A type of Schizophrenia in which the following criteria are met:
Preoccupation with one or more delusions or frequent auditory hallucinations.
None of the following is prominent: disorganized speech, disorganized
or catatonic behavior, or flat or inappropriate affect.
Catatonic
Type
A type of Schizophrenia in which the clinical picture is dominated
by at least two of the following:
motoric immobility as evidenced by catalepsy (including waxy flexibility)
or stupor
excessive motor activity (that is apparently purposeless and not influenced
by external stimuli)
extreme negativism (an apparently motiveless resistance to all instructions
or maintenance of a rigid posture against attempts to be moved) or
mutism
peculiarities of voluntary movement as evidenced by posturing (voluntary
assumption of inappropriate or bizarre postures), stereotyped movements,
prominent mannerisms, or prominent grimacing
echolalia or echopraxia
Disorganized
Type
A type of Schizophrenia in which the following criteria are met:
All of the following are prominent:
disorganized speech
disorganized behavior
flat or inappropriate affect
The criteria are not met for Catatonic Type.
Undifferentiated
Type
A type of Schizophrenia in which symptoms that meet Criterion A are
present, but the criteria are not met for the Paranoid, Disorganized,
or Catatonic Type.
Residual
Type
A type of Schizophrenia in which the following criteria are met:
Absence of prominent delusions, hallucinations, disorganized speech,
and grossly disorganized or catatonic behavior.
There is continuing evidence of the disturbance, as indicated by the
presence of negative symptoms or two or more symptoms listed in Criterion
A for Schizophrenia, present in an attenuated form (e.g., odd beliefs,
unusual perceptual experiences).
European
Description
The schizophrenic disorders are characterized in general by fundamental
and characteristic distortions of thinking and perception, and by
inappropriate or blunted affect. Clear consciousness and intellectual
capacity are usually maintained, although certain cognitive deficits
may evolve in the course of time. The disturbance involves the most
basic functions that give the normal person a feeling of individuality,
uniqueness, and self-direction. The most intimate thoughts, feelings,
and acts are often felt to be known to or shared by others, and explanatory
delusions may develop, to the effect that natural or supernatural
forces are at work to influence the afflicted individual's thoughts
and actions in ways that are often bizarre. The individual may see
himself or herself as the pivot of all that happens. Hallucinations,
especially auditory, are common and may comment on the individual's
behaviour or thoughts. Perception is frequently disturbed in other
ways: colours or sounds may seem unduly vivid or altered in quality,
and irrelevant features of ordinary things may appear more important
than the whole object or situation. Perplexity is also common early
on and frequently leads to a belief that everyday situations possess
a special, usually sinister, meaning intended uniquely for the individual.
In the characteristic schizophrenic disturbance of thinking, peripheral
and irrelevant features of a total concept, which are inhibited in
normal directed mental activity, are brought to the fore and utilized
in place of those that are relevant and appropriate to the situation.
Thus thinking becomes vague, elleptical, and obscure, and its expression
in speech sometimes incomprehensible. Breaks and interpolations in
the train of thought are frequent, and thoughts may seem to be withdrawn
by some outside agency. Mood is characteristically shallow, capricious,
or incongruous. Ambivalence and disturbance of volition may appear
as inertia, negativism, or stupor. Catatonia may be present. The onset
may be acute, with seriously disturbed behaviour, or insidious, with
a gradual development of odd ideas and conduct. The course of the
disorder shows equally great variation and is by no means inevitably
chronic or deteriorating (the course is specified by five-character
categories). In a proportion of cases, which may vary in different
cultures and populations, the outcome is complete, or nearly complete,
recovery. The sexes are approximately equally affected by the onset
tends to be later in women.
Although
no strictly pathognomonic symptoms can be identified, for practical
purposes it is useful to divide the above symptoms into groups that
have special importance for the diagnosis and often occur together,
such as:
(a)
thought echo, thought insertion or withdrawal, and thought broadcasting;
(b) delusions of control, influence, or passivity, clearly referred
to body or limb movements or specific thoughts, actions, or sensations;
delusional perception;
(c) hallucinatory voices giving a running commentary on the patient's
behaviour, or discussing the patient among themselves, or other types
of hallucinatory voices coming from some part of the body;
(d) persistent delusions of other kinds that are culturally inappropriate
and completely impossible, such as religious or political identity,
or superhuman powers and abilities (e.g. being able to control the
weather, or being in communication with aliens from another world);
(e) persistent hallucinations in any modality, when accompanied either
by fleeting or half-formed delusions without clear affective content,
or by persistent over-valued ideas, or when occurring every day for
weeks or months on end;
(f) breaks or interpolations in the train of thought, resulting in
incoherence or irrelevant speech, or neologisms;
(g) catatonic behaviour, such as excitement, posturing, or waxy flexibility,
negativism, mutism, and stupor;
(h) "negative" symptoms such as marked apathy, paucity of
speech, and blunting or incongruity of emotional responses, usually
resulting in social withdrawal and lowering of social performance;
it must be clear that these are not due to depression or to neuroleptic
medication;
(i) a significant and consistent change in the overall quality of
some aspects of personal behaviour, manifest as loss of interest,
aimlessness, idleness, a self-absorbed attitude, and social withdrawal.
Diagnostic
Guidelines
The normal requirement for a diagnosis of schizophrenia is that a
minimum of one very clear symptom (and usually two or more if less
clear-cut) belonging to any one of the groups listed as (a) to (d)
above, or symptoms from at least two of the groups referred to as
(e) to (h), should have been clearly present for most of the time
during a period of 1 month or more. Conditions meeting such symptomatic
requirements but of duration less than 1 month (whether treated or
not) should be diagnosed in the first instance as acute schizophrenia-like
psychotic disorder and are classified as schizophrenia if the sumptoms
persist for longer periods.
Viewed
retrospectively, it may be clear that a prodromal phase in which symptoms
and behaviour, such as loss of interest in work, social activities,
and personal appearance and hygiene, together with generalized anxiety
and mild degrees of depression and preoccupation, preceded the onset
of psychotic symptoms by weeks or even months. Because of the difficulty
in timing onset, the 1-month duration criterion applies only to the
specific symptoms listed above and not to any prodromal nonpsychotic
phase.
The
diagnosis of schizophrenia should not be made in the presence of extensive
depressive or manic symptoms unless it is clear that schizophrenic
symptoms antedated the affective disturbance. If both schizophrenic
and affective symptoms develop together and are evenly balanced, the
diagnosis of schizoaffective disorder should be made, even if the
schizophrenic symptoms by themselves would have justified the diagnosis
of schizophrenia. Schizophrenia should not be diagnosed in the presence
of overt brain disease or during states of drug intoxication or withdrawal.
F20.0
Paranoid Schizophrenia
This is the commonest type of schizophrenia in most parts of the world.
The clinical picture is dominated by relatively stable, often paranoid,
delusions, usually accompanied by hallucinations, particularly of
the auditory variety, and perceptual disturbances. Disturbances of
affect, volition, and speech, and catatonic symptoms, are not prominent.
Examples
of the most common paranoid symptoms are:
(a)
delusions of persecution, reference, exalted birth, special mission,
bodily change, or jealousy;
(b) hallucinatory voices that threaten the patient or give commands,
or auditory hallucinations without verbal form, such as whistling,
humming, or laughing;
(c) hallucinations of smell or taste, or of sexual or other bodily
sensations; visual hallucinations may occur but are rarely predominant.
Thought
disorder may be obvious in acute states, but if so it does not prevent
the typical delusions or hallulcinations from being described clearly.
Affect is usually less blunted than in other varieties of schizophrenia,
but a minor degree of incongruity is common, as are mood disturbances
such as irritability, sudden anger, fearfulness, and suspicion. "Negative"
symptoms such as blunting of affect and impaired volition are often
present but do not dominate the clinical picture.
The
course of paranoid schizophrenia may be episodic, with partial or
complete remissions, or chronic. In chronic cases, the florid symptoms
persist over years and it is difficult to distinguish discrete episodes.
The onset tends to be later than in the hebephrenic and catatonic
forms.
Diagnostic
Guidelines
The general criteria for a diagnosis of schizophrenia (see introduction
to F20 above) must be satisfied. In addition, hallucinations and/or
delusions must be prominent, and disturbances of affect, volition
and speech, and catatonic symptoms must be relatively inconspicuous.
The hallucinations will usually be of the kind described in (b) and
(c) above. Delusions can be of almost any kind of delusions of control,
influence, or passivity, and persecutory beliefs of various kinds
are the most characteristic.
Includes:
* paraphrenic schizophrenia
Differential
diagnosis. It is important to exclude epileptic and drug-induced psychoses,
and to remember that persecutory delusions might carry little diagnostic
weight in people from certain countries or cultures.
Excludes:
* involutional paranoid state (F22.8)
* paranoia (F22.0)
Hebephrenic
Schizophrenia
A form of schizophrenia in which affective changes are prominent,
delusions and hallucinations fleeting and fragmentary, behaviour irresponsible
and unpredictable, and mannerisms common. The mood is shallow and
inappropirate and often accompanied by giggling or self-satisfied,
self-absorbed smiling, or by a lofty manner, grimaces, mannerisms,
pranks, hypochondriacal complaints, and reiterated phrases. Thought
is disorganized and speech rambling and incoherent. There is a tendency
to remain solitary, and behaviour seems empty of purpose and feeling.
This form of schizphrenia usually starts between the ages of 15 and
25 years and tends to have a poor prognosis because of the rapid development
of "negative" symptoms, particularly flattening of affect
and loss of volition.
In
addition, disturbances of affect and volition, and thought disorder
are usually prominent. Hallucinations and delusions may be present
but are not usually prominent. Drive and determination are lost and
goals abandoned, so that the patient's behaviour becomes characteristically
aimless and empty of purpose. A superficial and manneristic preoccupation
with religion, philosophy, and other abstract themes may add to the
listener's difficulty in following the train of thought.
Diagnostic
Guidelines
The general criteria for a diagnosis of schizophrenia (see introduction
to F20 above) must be satisified. Hebephrenia should normally be diagnosed
for the first time only in adolescents or young adults. The premorbid
personality is characteristically, but not necessarily, rather shy
and solitary. For a confident diagnosis of hebephrenia, a period of
2 or 3 months of continuous observation is usually necessary, in order
to ensure that the characteristic behaviours described above are sustained.
Includes:
* disorganized schizophrenia
* hebephrenia
F20.2
Catatonic Schizophrenia
Prominent psychomotor disturbances are essential and dominant features
and may alternate between extremes such as hyperkinesis and stupor,
or automatic obedience and negativism. Constrained attitudes and postures
may be maintained for long periods. Episodes of violent excitement
may be a striking feature of the condition.
For
reasons that are poorly understood, catatonic schizophrenia is now
rarely seen in industrial countries, though it remains common elsewhere.
These catatonic phenomena may be combined with a dream-like (oneiroid)
state with vivid scenic hallucinations.
Diagnostic
Guidelines
The general criteria for a diagnosis of schizophrenia (see introduction
to F20 above) must be satisfied. Transitory and isolated catatonic
symptoms may occur in the context of any other subtype of schizophrenia,
but for a diagnosis of catatonic schizophrenia one or more of the
following behaviours should dominate the clinical picture:
(a)
stupor (marked decrease in reactivity to the environment and in spontaneous
movements and activity) or mutism;
(b) excitement (apparently purposeless motor activity, not influenced
by external stimuli);
(c) posturing (voluntary assumption and maintenance of inappropriate
or bizarre postures);
(d) negativism (an apparently motiveless resistance to all instructions
or attempts to be moved, or movement in the opposite direction);
(e) rigidity (maintenance of a rigid posture against efforts to be
moved);
(f) waxy flexibility (maintenance of limbs and body in externally
imposed positions); and
(g) other symptoms such as command automatism (automatic compliance
with instructions), and perseveration of words and phrases.
In
uncommunicative patients with behavioural manifestations of catatonic
disorder, the diagnosis of schizophrenia may have to be provisional
until adequate evidence of the presence of other symptoms is obtained.
It is also vital to appreciate that catatonic symptoms are not diagnostic
of schizophrenia. A catatonic symptom or symptoms may also be provoked
by brain disease, metabolic disturbances, or alcohol and drugs, and
may also occur in mood disorders.
Includes:
* catatonic stupor
* schizophrenic catalepsy
* schizophrenic catatonia
* schizophrenic flexibilitas cerea
F20.3
Undifferentiated Schizophrenia
Conditions meeting the general diagnostic criteria for schizophrenia
(see introduction to F20 above) but not conforming to any of the above
subtypes, or exhibiting the features of more than one of them without
a clear predominance of a particular set of diagnostic characteristics.
This rubric should be used only for psychotic conditions (i.e. residual
schizophrenia and post-schizophrenic depression are excluded) and
after an attempt has been made to classify the condition into one
of the three preceding categories.
Diagnostic
Guidelines
This category should be reserved for disorders that:
(a)
meet the diagnostic criteria for schizophrenia;
(b) do not satisfy the criteria for the paranoid, hebephrenic, or
catatonic subtypes;
(c) do not satisfy the criteria for residual schizophrenia or post-schizophrenic
depression.
Includes:
atypical schizophrenia
F20.4
Post-Schizophrenic Depression
A depressive episode, which may be prolonged, arising in the aftermath
of a schizophrenic illness. Some schizophrenic symptoms must still
be present but no longer dominate the clinical picture. These persisting
schizophrenic symptoms may be "positive" or "negative",
though the latter are more common. It is uncertain, and immaterial
to the diagnosis, to what extent the depressive symptoms have merely
been uncovered by the resolution of earlier psychotic symptoms (rather
than being a new development) or are an intrinsic part of schizophrenia
rather than a psychological reaction to it. They are rarely sufficiently
severe or extensive to meet criteria for a severe depressive episode,
and it is often difficult to decide which of the patient's symptoms
are due to depression and which to neuroleptic medication or to the
impaired volition and affective flattening of schizophrenia itself.
This depressive disorder is associated with an increased risk of suicide.
Diagnostic
Guidelines
The diagnosis should be made only if:
(a)
the patient has had a schizophrenic illness meeting the general criteria
for schizophrenia (see introduction to F20 above) within the past
12 months;
(b) some schizophrenic symptoms are still present; and
(c) the depressive symptoms are prominent and distressing, fulfilling
at least the criteria for a depressive episode, and havew been present
for at least 2 weeks.
If
the patient no longer has any schizophrenic symptoms, a depressive
episode should be diagnosed. If schizophrenic symptoms are still florid
and prominent, the diagnosis should remain that of the appropriate
schizophrenic subtype.
F20.5
Residual Schizophrenia
A chronic stage in the development of a schizophrenic disorder in
which there has been a clear progression from an early stage (comprising
one or more episodes with psychotic symptoms meeting the general criteria
for schizophrenia described above) to a later stage characterized
by long-term, though not necessarily irreversible, "negative"
symptoms.
Diagnostic
Guidelines
For a confident diagnosis, the following requirements should be met:
(a)
prominent "negative" schizophrenic symptoms, i.e. psychomotor
slowing, underactivity, blunting of affect, passivity and lack of
initiative, poverty of quantity or content of speech, poor nonverbal
communication by facial expression, eye contact, voice modulation,
and posture, poor self-care and social performance;
(b) evidence in the past of at least one clear-cut psychotic episode
meeting the diagnostic criteria for schizophrenia;
(c) a period of at least 1 year during which the intensity and frequency
of florid symptoms such as delusions and hallucinations have been
minimal or substantially reduced and the "negative" schizophrenic
syndrome has been present;
(d) absence of dementia or other organic brain disease or disorder,
and of chronic depression or institutionalism sufficient to explain
the negative impairments.
If
adequate information about the patient's previous history cannot be
obtained, and it therefore cannot be established that criteria for
schizophrenia have been met at some time in the past, it may be necessary
to make a provisional diagnosis of residual schizophrenia.
Includes:
* chronic undifferentiated schizophrenia
* "Restzustand"
* schizophrenic residual state
F20.6
Simple Schizophrenia
An uncommon disorder in which there is an insidious but progressive
development of oddities of conduct, inability to meet the demands
of society, and decline in total performance. Delusions and hallucinations
are not evident, and the disorder is less obviously psychotic than
the hebephrenic, paranoid, and catatonic subtypes of schizophrenia.
The characteristic "negative" features of residual schizophrenia
(e.g. blunting of affect, loss of volition) develop without being
preceded by any overt psychotic symptoms. With increasing social impoverishment,
vagrancy may ensue and the individual may then become self-absorbed,
idle, and aimless.
Diagnostic
Guidelines
Simple schizophrenia is a difficult diagnosis to make with any confidence
because it depends on establishing the slowly progressive development
of the characteristic "negative" symptoms of residual schizophrenia
without any history of hallucinations, delusions, or other manifestations
of an earlier psychotic episode, and with significant changes in personal
behaviour, manifest as a marked loss of interest, idleness, and social
withdrawal.
Includes:
* schizophrenia simplex